Provider Demographics
NPI:1588058812
Name:ALT, MIKAELA (DC)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:ALT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BRANCH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-9703
Mailing Address - Country:US
Mailing Address - Phone:816-431-0353
Mailing Address - Fax:816-858-7017
Practice Address - Street 1:200 BRANCH ST
Practice Address - Street 2:SUITE C
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9703
Practice Address - Country:US
Practice Address - Phone:816-431-0353
Practice Address - Fax:816-858-7017
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05688111N00000X
MO2015005922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor